JMIR Publications

ABSTRACT

Background:

Delayed discharge among older patients presents a major challenge for the efficiency of health service delivery. Lengthy hospital stays limit bed turnover, increase costs, and reduce the availability of hospital resources. In Japan, older adults must undergo a formal care-needs certification process to access public long-term care (LTC) services. Initiating this process during hospitalization is considered ideal for ensuring continuity of care. However, the relationship between the timing of LTC certification applications and hospital length of stay (LOS) remains unclear.

Objective:

This study aimed to examine the association between the timing of LTC certification applications—specifically those submitted during hospitalization—and the average LOS among older inpatients across Japanese prefectures.

Methods:

We conducted an ecological cross-sectional study using data from all 47 prefectures in Japan for fiscal year (FY) 2020. The exposure variable was the proportion of LTC certification applications submitted during hospitalization among all new LTC applications in each prefecture. The outcome variable was the average LOS among individuals aged 65 years or older, based on the 2020 Patient Survey. Additional data were obtained from the Second Long-Term Care Database Open Data. Linear regression models were used to evaluate the association between the exposure and outcome variables. Covariates included proportions of residents living alone, with cognitive decline, or with higher dependency; the proportion requiring dialysis or a respirator before application; and the number of nursing and care home beds per 1,000 LTC recipients.

Results:

The median proportion of in-hospital LTC certification applications was 30.5% (interquartile range: 24.5%–36.1%). The median average LOS for older adults was 40 days (range: 30–82 days). Prefectures with a higher proportion of in-hospital applications had significantly longer average LOS. In univariate analysis, a 1% increase in in-hospital applications was associated with an approximately 2-day increase in average LOS. This association remained statistically significant after adjustment for all covariates in multivariate models（β=0.06, P=0.035）.

Conclusions:

Although initiating LTC certification during hospitalization is often regarded as a strategy to support timely discharge, our findings indicate a positive association between its prevalence and longer hospital stays. This relationship may reflect systemic delays in the certification process or limited availability of post-discharge care resources. As this study is ecological in design, findings should be interpreted with caution. Further research using individual-level data is warranted to explore mechanisms and inform strategies for improving transitional care efficiency in aging populations.